How the DSM-5 Got Grief, Bereavement Right

One of the charges leveled against psychiatry’s diagnostic categories is that they are often “politically motivated.” If that were true, the framers of the DSM-5 probably would have retained the so-called “bereavement exclusion” — a DSM-IV rule that instructed clinicians not to diagnose major depressive disorder (MDD) after the recent death of a loved one (bereavement) — even when the patient met the usual MDD criteria. An exception could be made only in certain cases; for example, if the patient were psychotic, suicidal, or severely impaired.

And yet, in the face of fierce criticism from many groups and organizations, the DSM-5 mood disorder experts stuck to the best available science and eliminated this exclusion rule.

The main reason is straightforward: most studies in the past 30 years have shown that depressive syndromes in the context of bereavement aren’t fundamentally different from depressive syndromes after other major losses — or from depression appearing “out of the blue.” (see Zisook et al, 2012, below). At the same time, the DSM-5 takes pains to parse the substantial differences between ordinary grief and major depressive disorder.

Unfortunately, the DSM-5’s decision continues to be misrepresented in the popular media.

Consider, for example, this statement in a recent (5/15/13) Reuters press release:

“Now [with DSM-5], if a father grieves for a murdered child for more than a couple of weeks, he is mentally ill.”

This statement is patently false and misleading. There is nothing in the elimination of the bereavement exclusion that would label bereaved persons “mentally ill” simply because they are “grieving” for their lost loved ones. Nor does the DSM-5 place any arbitrary time limit on ordinary grief, in the context of bereavement — another issue widely misrepresented in the general media, and even by some clinicians.

By removing the bereavement exclusion, the DSM-5 says this: a person who meets the full symptom, severity, duration and impairment criteria for major depressive disorder (MDD) will no longer be denied that diagnosis, solely because the person recently lost a loved one. Importantly, the death may or may not be the main, underlying cause of the person’s depression. There are, for example, many medical causes for depression that may happen to coincide with a recent death.

True: the two-week minimum duration for diagnosing MDD has been carried over from DSM-IV to DSM-5, and this remains problematic. My colleagues and I would have preferred a longer minimum period — say, three to four weeks — for diagnosing milder cases of depression, regardless of the presumed cause or “trigger.” Two weeks is sometimes not enough to permit a confident diagnosis, but this is true whether depression occurs after the death of a loved one; after the loss of house and home; after a divorce — or when depression appears “out of the blue.” Why single out bereavement? Retaining the bereavement exclusion would not have solved the DSM-5’s “two-week problem.”

And yet, nothing in the DSM-5 will compel psychiatrists or other clinicians to diagnose MDD after just two weeks of post-bereavement depressive symptoms. (Practically speaking, it would be rare for a bereaved person to seek professional help only two weeks after the death, unless suicidal ideation, psychosis, or extreme impairment was present — in which case, the bereavement exclusion would not have applied anyway).

Clinical judgment may warrant deferring the diagnosis for a few weeks, in order to see whether the bereaved patient “bounces back” or worsens. Some patients will improve spontaneously, while others will need only a brief period of supportive counseling — not medication. And, contrary to the claims of some critics, receiving the diagnosis of major depression will not prevent bereaved patients from enjoying the love and support of family, friends, or clergy.

Most people grieving the death of a loved one do not develop a major depressive episode. Nevertheless, DSM-5 makes it clear that grief and major depression may exist “side by side.” Indeed, the death of a loved one is a common “trigger” for a major depressive episode — even as the bereaved person continues to grieve.

The DSM-5 provides the clinician with some important guidelines that help distinguish ordinary grief — which is usually healthy and adaptive — from major depression. For example, the new manual notes that bereaved persons with normal grief often experience a mixture of sadness and more pleasant emotions, as they remember the deceased. Their very understandable anguish and pain are usually experienced in “waves” or “pangs,” rather than continuously, as is usually the case in major depression.

The normally grieving person typically maintains the hope that things will get better. In contrast, the clinically depressed person’s mood is almost uniformly one of gloom, despair, and hopelessness — nearly all day, nearly every day. And, unlike the typical bereaved person, the individual with major depression is usually quite impaired in terms of daily functioning.

Furthermore, in ordinary grief, the person’s self-esteem usually remains intact. In major depression, feelings of worthlessness and self-loathing are very common. In ambiguous cases, a patient’s history of previous depressive bouts, or a strong family history of mood disorders, may help clinch the diagnosis.

Finally, the DSM-5 acknowledges that the diagnosis of major depression requires the exercise of sound clinical judgment, based on the individual’s history and “cultural norms” — thus recognizing that different cultures and religions express grief in different ways and to varying degrees.

The monk Thomas a Kempis wisely noted that human beings must sometimes endure “proper sorrows of the soul,” which do not belong in the realm of disease. Neither do these sorrows require “treatment” or medication. However, the DSM-5 rightly recognizes that grief does not immunize the bereaved person against the ravages of major depression—a potentially lethal yet highly treatable disorder.